Eastern Oklahoma Orthopedic Center Dr. R. Tyler Boone Orthopedic

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					Eastern Oklahoma Orthopedic Center
                 Dr. R. Tyler Boone
          Orthopedic Spinal Surgeon
A medical term that refers to fabricating or
exaggerating the symptoms of mental or
physical disorders for a variety of secondary
gain motives.

◦ Intentional, deceptive behavior
◦ Not a medical or psychiatric disorder
◦ Diagnosis rests upon identification of external or
  “secondary” gain being present as main
  motivation.
Avoidance of going
to jail, avoidance
of work or family
responsibility
Desire to obtain
narcotics
Desire to be
awarded money in
litigation
Need for
attention/sympathy
Factitious disorder/Munchausen Syndrome by
proxy…

◦ Deliberate effort to produce physical or psychological
  symptoms in order to gain attention

◦ Conscious production of symptoms

◦ Unconscious motivation

◦ Munchausen Syndrome by proxy is creating illness or
  injury in another
Hypochondriasis

◦ Excessive
  preoccupation
  with bodily
  sensation or
  unrealistic fears of
  illness
Conversion disorder
◦ Unconscious disorder that
  produces pseudo physiologic
  symptoms to help resolve
  personal conflict.

Somatization Disorder
◦ Multiple complaints involving various
  organ symptoms.
Partial Malingering

 Individual has
 symptoms but
 exaggerates impact
                      False Imputation
 upon daily
 functioning.
                      Individual has valid
 (“Functional         symptoms but is
 overlay” on an       dishonest as to
 existing disease,    source of problems
 “symptom             (injury at home)
 magnification”).
1.   Dramatic or atypical presentation
2.   Vague and inconsistent history details
3.   History of multiple admissions to
     various hospitals
4.   Substance abuse
5.   Presentation to emergency
     departments at odd times
6.   Controlling, hostile, angry,
     Disruptive, attention-seeking
     behavior
       7. Fluctuating clinical course with
          rapid development of new
          symptoms if initial work up negative
       8. Symptoms or behaviors only
          present when patient knows he or
          she is being observed.
9.  Changing doctors when release
    for work issued.
10. Lack of cooperation and
    noncompliance with treatment
11. Anti-social or borderline
    personality.
    F-scale called
    malingering index
    F-K score can
    distinguish malingerer’s
    from non-malingerer’s.
     Table 4. Correlation Between Nonorganic Signs and Minnesota
     Multiphasic Personality Inventory (MMPI) * .

                     Hs         D         Hy
    Tenderness          0.22              029


    Simulation          0.20    0.23      0.20


    Distraction                 0.29      0.23


    Regional            0.19              0.22


    Overreaction                0.18




* Study 1, 84 patients: Pearsonian correlation coefficients confirmed by
corrected x2 analysis
       Hs = hypochondriasis. D = depression. Hy = hysteria
I.      A Set of Five Types of Nonorganic Physical
        Signs In Low Back Pain
II.     Can Be Used to Screen Individuals Who
        Require Detailed Psychological Assessment
III.    Scoring
       A. Any individual sign counts as positive for that
          type
       B. Three or more types positive= clinically
          significant
A. Tenderness
     Superficial- skin is tender to light pinch over a wide
     area of lumbar skin
     Non-anatomic- deep tenderness over a wide area, not
     localized to one structure, often extends to thoracic
     spine, sacrum, or pelvis

B. Simulation Test-
   Give the impression that an examination is being
   done, when in fact it is not.

   1. Axial loading- vertical loading over the standing
   patient’s skull by the examiner’s hands- may cause
   neck pain, but shouldn’t cause low back pain.
   1. Rotation- turn standing patient to one
      side by rotating lower extremities (not
       spine)

C. Distraction Tests- reevaluating a positive
   finding while the patient’s attention is not
   focused on the test- distraction must be
   non-painful, non-emotional, and non-
   surprising
   1. Indirect observation- can patient move
      the body party without pain when not
      being directly examined?
 2. straight leg raise- if positive when
    examined supine, do “flip test” (sitting
    SLR)- can be done while testing for
    Babinski sign while sitting- if no pain in
    sitting then distraction sign is positive
D. Regional Disturbance- widespread
    vergence from accepted neuro-anatomy
 1. Weakness- “cogwheeling” of many
    muscle groups that cannot be explained
    neuroanatomically
 2. Sensory- “stocking” distribution of
    sensory changes
E. Overreaction
    1. disproportionate verbalization, facial
    expression, muscle tension and tremor,
    collapsing, sweating.
    2. most difficult type of sign to assess
    because:
          a. cultural variation
          b. examiner bias
 In absence of clear indications for surgery
 may give sufficient cause not to embark on
 elaborate and risky preoperative
 investigations
 Even with proven and treatable physical
 lesion multiple nonorganic signs help to
 identify those patients requiring formal
 psychosocial assessment before surgery
 In Waddell’s study (1979) nonorganic signs
 were equally common among litigants and
 non-litigants.

Waddell G, McCulloch JA, Kummel E, Venner RM: Nonorganic
 physical sign in low-back pain. Spine, 5(2) 117-125,
 March/April 1980
Considered by adjuster when red flags in
claim, medical reports indicating malingering
Considered when employer learns employee
working at another job
Make sure surveillance on more than one day
(avoid “a good day” excuse)
Use carefully/follow discovery rules
Physicians must rule out sometimes
obscure conditions
◦ Tumor, infections
◦ Intractable pain, night pain, rest pain,
  systemic symptoms
◦ The presence of nonorganic signs, must
  not prevent the physical assessment and
  investigation of patients
Reduces productivity of industry or military
through absenteeism
Depletes private and governmental social
security, disability, worker’s compensation,
and insurance benefits
Drains medical system of resources
     “Fraud that broadly includes
   malingering costs the insurance
    industry $150 billion annually,
increasing cost of insurance by $1800
  per family” Psychiatric Times 2007.

				
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